1. Patient Safety You Can Make a Difference 2016

2. 2 Patient Safety is in the News HEADLINES … Doctor…cut off wrong leg Sponge left in woman’s body One in six NHS patients misdiagnosed Blogs Tweets Books

3. 3 Definitions in Patient Safety I Error: failure of a planned action or use of a wrong plan Adverse Event: commission or omission resulting in unintended harm to a patient Near miss: event caught before harming a patient Sentinel Event: event causing or risking serious injury or death

4. 4 Layers of Patient Safety Sharp End Examples: Medication adverse events Nosocomial Infections Blunt End Examples: Communication Culture Physical Environment Policies / Procedures Sharp End: Immediate Cause(s) Blunt End: Root Cause(s) Contributing Factors Patient / Health Care Provider / Team / Task and Environmental Factors Management/ Organizational/ Regulatory Factors Adapted from the National Health Service. Department of Health. National Patient Safety Agency. Doing Less Harm: improving the safety and quality of care through reporting, analyzing and learning from adverse incidents involving NHS patients – key requirements for health care providers, August 2001.

5. 5 Legislating Patient Safety Consumer Product Safety Act 1972 Safe Medical Device Amendments 1990 National Literacy Act 1991 HIPAA 1996 Healthcare Research and Quality Act 1999 Patient Safety and Quality Improvement Act 2005 Health Care Safety Net Act 2008 American Recovery and Reinvestment Act 2009 (HITECH) Affordable Care Act 2010

6. 6 State Reporting Systems See: http://www.nashp.org/patient-safety-toolkit/ and http://www.qups.org

7. 7 The Patient in Patient Safety The Agency for Healthcare Research and Quality (AHRQ) is one of several organizations with a section of their website focused on resources for patients and family members Patient advocates (often starting with their own experiences) have created advocacy organizations and written books to help others

8. 8 What Each Patient Can Do Individual Advocacy – In doctor & hospital visits – Share information Create a Personal Health Record or keep lists of health problems, previous operations, etc. List or bring all medications, supplements, and vitamins – Get information Ask questions about treatments, medications, etc. Research illnesses and treatments – Bring an Advocate – Know what to do before leaving Ask about medications and future appointments

9. 9 Support a Patient as an Advocate Patient Advocate – For friends and family – Go with the patient to appointments, be with them in the hospital and clinics – Listen and take notes – Speak up when necessary to clarify an issue and to ask a question – Question when something does not seem right in the hospital, nursing homes, clinics, etc.

10. 10 Represent the Patient Perspective Patient Advocacy – In health care organizations – Learn about the broader issues of patient safety – Work to improve safety at the organization and individual unit level – Serve on committees and boards, ex. Patient Safety Advisory Committee – Assist on rounds (still rare) – Support staff and families – Become a Patient Representative

11. 11 Become Involved Patient Activist – Participate on state and regional coalitions and organizations and/or – Serve nationally – Advocate for public reporting and accountability of hospital and health system performance – Volunteer, make donations, work with fund-raising – Be aware of state and national legislation, contact legislators Gibson, Rosemary. Role of the patient in improving patient safety. WebM&M. 2007(Mar): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38

12. 12 Patient Resources I Questions To Ask Your Doctor [before, during and after your appointment] (AHRQ) http://www.ahrq.gov/patients-consumers/patient- involvement/ask-your-doctor/ Speak Up Initiatives (and brochures) http://www.jointcommission.org/speakup.aspx Talking with your doctor: a guide for older people (NIA) https://www.nia.nih.gov/health/publication/talking-your-doctor/ We Care about Your Safety (video) http://www.emmisafety.com/ashrm/Emmi.html

13. 13 Patient Resources II Become more familiar with the medicine you take (ISMP) http://www.consumermedsafety.org/ How to Create a Pill Card (AHRQ) http://www.ahrq.gov/patients-consumers/diagnosis- treatment/treatments/pillcard/ Medicines and You: a guide for older adults (FDA) http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm Personal Health Records (NLM) https://www.nlm.nih.gov/medlineplus/personalhealthrecords.html

14. 14 NLM Patient Resources II ClinicalTrials.gov – http://clinicaltrials.gov Drug Information Portal – http://druginfo.nlm.nih.gov Genetics Home Reference – http://ghr.nlm.nih.gov Household Products Database – http://hpd.nlm.nih.gov MedlinePlus – http://medlineplus.gov NIH Senior Health – http://nihseniorhealth.gov Pillbox – http://pillbox.nlm.nih.gov PubMed – http://pubmed.gov Tox Town – http://toxtown.nlm.nih.gov

15. 15 Additional Resource Examples Advocacy Organizations – CAPS, Empowered patient, PULSE Conferences incorporating patient input – NPSF, Local coalitions Medical Error Support – MITSS, PULSE Research and Government Sites – AHRQ, CDC, NLM Reporting Errors – FDA, ISMP

16. 16 Quality Safety Patient and Patient family Safety involvement Culture Management Intersection of Patient Safety

17. You will make a difference Keep the Patient in Patient Safety